How It Works
CMS TEAM Analyzer is a warehouse-native dbt package. It reads Tuva-conformed claims and membership data, constructs TEAM episodes, assigns spend, resolves target prices, and publishes marts for reporting and action planning.
Processing Flow
- Stage Tuva inputs: medical claims, encounters, eligibility, patients, practitioners, and MS-DRG terminology are normalized behind package staging models.
- Find candidate anchors: inpatient MS-DRGs and outpatient HCPCS triggers identify possible TEAM episodes.
- Resolve episode rules: outpatient-to-inpatient precedence, overlap handling, death during anchor, and episode date windows are applied.
- Assign claims: claims overlapping the 30-day episode window are attached to the episode and classified into spend components.
- Apply exclusions and proration: available CMS-style exclusions and boundary proration logic reduce included spend where supported by source data.
- Calculate target prices: participant-specific CMS targets, public CMS regional PY1 targets, and local directional baselines are resolved into an active target price.
- Publish marts: episode, overview, performance-period, driver, care-pathway, opportunity, and reconciliation-style tables are built for downstream use.
Anchor Trigger Definitions
CMS defines TEAM episode initiation in 42 CFR § 512.525. The package-managed trigger seeds implement those inpatient MS-DRG and outpatient HCPCS definitions.
| Episode category | Inpatient anchor MS-DRGs | Outpatient anchor HCPCS |
|---|---|---|
| Lower Extremity Joint Replacement (LEJR) | 469, 470, 521, 522 | 27447, 27130, 27702 |
| Surgical Hip/Femur Fracture Treatment (SHFFT) | 480, 481, 482 | Not applicable |
| Coronary Artery Bypass Graft Surgery (CABG) | 231, 232, 233, 234, 235, 236 | Not applicable |
| Spinal Fusion | 402, 426, 427, 428, 429, 430, 447, 448, 450, 451, 471, 472, 473 | 22551, 22554, 22612, 22630, 22633 |
| Major Bowel Procedure | 329, 330, 331 | Not applicable |
For outpatient-triggered episodes, the package normalizes HCPCS triggers to MS-DRG-like target-price categories:
| Episode category | Outpatient HCPCS | Target MS-DRG category |
|---|---|---|
| LEJR | 27447, 27130 | 470 |
| LEJR | 27702 | 469 |
| Spinal Fusion | 22551, 22554 | 473 |
| Spinal Fusion | 22612, 22630 | 451 |
| Spinal Fusion | 22633 | 402 |
CMS also specifies outpatient-to-inpatient precedence: if a qualifying inpatient hospitalization starts on the same day or within 3 days after a qualifying outpatient procedure in the same episode category, the episode start date is the outpatient procedure date.
Target Price Precedence
The package chooses the best available target price for each episode:
| Priority | Source | When used |
|---|---|---|
| 1 | Participant-specific CMS target prices | Client supplies target-price rows from CMS participant/eDFR-style files |
| 2 | Public CMS PY1 regional target prices | Package finds a match by performance year, census division, bundle, and MS-DRG |
| 3 | Local directional baseline | Package estimates a planning benchmark from the client's baseline period |
This lets teams start quickly with public target data, then increase precision when official participant-specific files are available.
Implemented Analytics
- Episode construction for all five TEAM bundle categories
- Outpatient-to-inpatient anchor precedence
- Overlap suppression so the first active TEAM episode wins
- Claim assignment across anchor, professional, outpatient, post-acute, DME, hospice, and readmission components
- Post-episode days 31-60 monitoring
- Open episode status and spend-to-snapshot reporting
- Directional risk features including age band, disability, dual eligibility, lookback utilization, lookback spend, and prior post-acute care
- Hospital/site features including episode volume and safety-net proxy metrics
- Driver analysis by surgeon, anchor site, post-acute partner, discharge disposition, and episode category
Data Fidelity Notes
CMS TEAM Analyzer is built for operational planning and performance management. Some official CMS reconciliation details require data that is not always present in standard client claims feeds.
| Area | Current approach |
|---|---|
NTAP exclusion via value code 77 | Supported when usable value-code fields are supplied |
| OPPS pass-through device exclusion | Supported when OPPS status indicator data or mapping is supplied |
| CMS standardized allowed amount | Configurable only when the client supplies a standardized amount |
| CDI, LIS, LTI, and full CMS risk model features | Directional proxies today; optional enrichment path where data exists |
| Quality adjustment | Planned future scenario layer, not an official quality adjustment result |
| Final CMS reconciliation parity | Not claimed; official CMS files remain the source of truth |